Prof. James Spicer has come to the pub directly from his twice weekly lung cancer clinic at Guy’s gleaming cancer centre near London Bridge.
“The average person would expect me to come straight out of clinic and order a triple vodka to recover,” he jokes. “But the reality is not like that at all. I feel that in a clinic like ours I’m going around dispensing optimism.”
As if to demonstrate that it wasn’t too bad a day, he orders a pint of bitter rather than vodka, and gets straight to the point.
“People come to us thinking they have an irredeemable death sentence. But that is no longer the case. We are talking about options, which treatment will be best for you in which order, how soon we will know if it is working, what will we change to if it doesn’t work.
“In short,” he says, “there is so much to discuss and be optimistic about.”
Look at survival rates for different types of cancer, it is undeniable that lung cancer is one of those diseases that still carries a relatively poor prognosis – and that has not improved significantly over the years, unlike for blood or breast cancer, for example.
Lung cancer is especially chaotic and complex
There are many reasons for that, not least the complexity of lung cancer. Unlike certain leukemias or lymphomas, for example, which are caused by one genetic malfunction, the kind of lung cancer contracted by a smoker is typically “chaotic,” meaning there are dozens of cancer genes doing their evil work. This has made lung cancer especially resistant to traditional forms of treatment.
The reason for Prof Spicer’s optimism is the new science of immunotherapy, whereby the body is encouraged to use the powers of its own immune system to attack and destroy cancer cells. This is distinct from old-fashioned chemotherapy and the targeted therapies that tackle cancer-causing genetic abnormalities.
“I’ve been in my post eleven years, and when I started, nobody had really heard of immunotherapy,” Spicer explains. “I’d go to a big cancer conference and there’s be a small room at the back dedicated to this weird new field. Now it’s more like 70 per cent of all the new data presented relates to immunotherapy.”
Prof Spicer has an unusual background for a cancer specialist. After studying at Oxford, he worked for a spell as an investment banker before returning to study medicine. He now has a job that requires crossing from one end of the car park (the science labs) to the other (the clinic), straddling both research (into new forms of treatment) and patient care. He is Professor of Experimental Cancer Medicine, King’s College London, and Consultant in Medical Oncology, Guy’s and St. Thomas’ Hospitals London, UK
Immunotherapy holds out the promise of revolutionary benefits
Immunotherapy has already delivered revolutionary benefits for melanoma and other diseases, and offers huge hope, not just for lung cancer but also other intractable diseases like pancreatic cancer. It’s not without its side effects, and is far from a panacea, but Dr Spicer is excited about its potential.
The revelation came around the turn of this century, when scientists realised that “combination therapy,” putting together cocktails of poisonous chemo, was something of a dead end (forgive the pun). At the same time, the biology of cancer was becoming better understood.
One outcome was so-called monoclonal antibodies, drugs that go after specific cancer cells. They are designed to go in hard by targeting a single genetic abnormality and as a result can be more effective than the blunderbluss of chemo. Herceptin, used to treat breast cancer, is an example of one these targeted therapies.
After chemo and targeted therapy, immunotherapy is the “third way” that has come into its own in the past five years. The magic of this kind of treatment is that it is targeted not at the cancer, but at the immune system.
Normal cells are successful in sending signals to the immune system. When there is something wrong, the system switches on and puts things right. With Darwinian deviousness, cancer cells are often successful in faking things so that the immune system is tricked into thinking there is nothing amiss.
Interrogating cancer cells more effectively
“Cancer cells have mechanisms to push away immune cells,” Spicer explains, clearly slowing down as he knows he is talking to a layman. “Now we can block those mechanisms so that the immune system can wade in and do the job we want it to do.”
This is the new paradigm: the immune system’s very own T-Cells trained to interrogate cancer cells more effectively than they could do the job on their own.
There is a paradoxical hope for those with nasty, chaotic lung cancer caused by smoking: this presents a better target for immunotherapy drugs, than other types of lung cancer where the diseased cells more easily pass themselves off as normal.
There is hope elsewhere, as more than 50 per cent of lung cancers now have a “biomarker” i.e. a genetic malfunction that is understood, recognisable and treatable – either by the new immunotherapy or drugs targeted at specific variations (e.g. the EGFR marker).
In future posts, we will examine the science in more detail. For now, here is Prof Spicer’s message of realism balanced by hope:
“Don’t get me wrong,” he says. “Lung cancer is still a pretty grim diagnosis, and for every poster child patient who is doing spectacularly well on the new drugs, there are lots of patients who have horrible diseases that don’t respond to anything. But there is is enough going on to be really optimistic about, and it’s really important to me that patients pick up on this positive psychology.”
This is a sentiment we can all raise a glass to.